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Deletion of Activity

FDA drugstore form for deletion of activity

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
Department of Health
FOOD AND DRUG ADMINISTRATION

CENTER FOR DRUG REGULATION AND RESEARCH
DRUGSTORE (

) / HOSPITAL PHARMACY (

) / INSTITUTIONAL PHARMACY (

SELF-ASSESSMENT TOOLKIT FORM

COMPANY NAME
COMPANY ADDRESS
OWNER
ACTIVITY TO BE
DELETED
LTO NUMBER
VALIDITY

DELETION OF ACTIVITY
:
:
:
: NON-STERILE OMPOUNDING
ONLINE ORDERING AND DELIVERY
STERILE COMPOUNDING
MOBILE PHARMACY
:
:

Directions:
Fill out the form by ticking the applicable box. Provide remarks on the client’s column when necessary.
Submit in Portable Document Format (pdf) and word format duly signed by the pharmacist/owner.

DOCUMENTARY REQUIREMENTS:


1. Application Form
Is the integrated application form properly filled out?




Is it duly notarized?
Are the signatories of the application form the authorized
persons as required under the following circumstances?
(a) If single proprietorship – the owner as registered in DTI
(unless there is a different authorized person)
(b) If partnership/corporation – one of the incorporators or
authorized person as indicated in the board resolution
and/or Secretary’s Certificate
(c) If cooperative – authorized person indicated in the
board resolution and/or Secretary’s Certificate of the
cooperative
If the signatory is not the owner or one of the incorporators, as
the case may be:

Is there a board resolution or notarized Secretary’s
Certificate clearly identifying the person authorized to sign
for and in behalf of the owner or corporation submitted?
For government-owned or controlled corporation:


Is there an Order (or equivalent document) identifying the
person authorized to sign for and in behalf of the
establishment submitted?

2. Proof of Payment
 Is the payment made according to the required fee?

Yes

No

REMARKS
CLIENT

FDA

)

 Is there a scanned copy of proof of payment (e.g FDA official
receipt, Landbank On-coll validated slip ) submitted?

Prepared by:
Position (Pharmacist / Owner):
Decision:
Approval
Denial
Clarification
Inspection

Remarks:

Decision:
Approval
Clarification
Evaluated by:

--- To be filled out by client: --Signature:
Date:
--- To be filled out by RFO: ---

Remarks:

Evaluated by:

Date:
--- To be filled out by CDRR: ---

Date:
 
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